A fair assessment of the budget deal signed by President Obama last week would allow for only at most two cheers. Its biggest achievement is raising the debt limit by enough to last until 2017, thereby at least temporarily eliminating the threat to the nation's credit worthiness. The deal also provides funding levels above the Spartan caps established by the 2011 Budget Control Act so that both domestic discretionary spending and military spending can avoid reductions against a baseline that was already low by historical standards. In addition, the deal avoids a cut in benefits in the Social Security Disability Insurance (SSDI) program that was about to have its trust account run dry, as well as a big increase in payments by a significant minority of Medicare beneficiaries.

That's a lot of good policy, achieved despite the partisanship that has been so characteristic of budget negotiations in recent years. So what's not to like? Two shortcomings of the deal are especially notable. The first is that the solution to the pending SSDI shortfall is disappointing. It would be hard to support the imposition of reduced benefits on recipients of a government insurance program for the disabled, but Congress has known for some years that SSDI was running out of money. Congress should have been working on solutions that involved less spending or more revenue, or perhaps both. Instead, the reforms that Congress passed provided a very minor adjustment in the way both initial and continuing eligibility are determined and ignored more basic reforms. A non-partisan group assembled by former House members Jim McCrery and Earl Pomeroy under the auspices of the Committee for a Responsible Federal Budget (CRFB) produced a host of proposals that would address the underlying problems of the SSDI program such as how to emphasize work to control the rising caseload, but they were virtually ignored. Taking the easy way out, Congress transferred nearly $120 billion in funds from the Social Security Trust Fund into the SSDI Trust Fund. Unfortunately, this action will preserve the SSDI Trust Fund only until 2021 or 2022, at which time it will likely be back in the perilous situation it was in until this temporary fix was put in place.

The second problem is that the lubricant Congress used to enact the deal was money it doesn't have. Thus, according to CRFB, all the spending in the deal cost $154 billion but the offsets in the bill amounted to only $78 billion. Thus, the true net cost of the bill, excluding budget gimmicks, was $76 billion. As always, the money will be obtained by additional borrowing, thereby increasing the nation's debt.

Increasing the nation's debt is the most important shortcoming of the bill. Due to improvements in the economy coupled with spending cuts and revenue increases achieved by previous budget deals reached since publication of the Simpson-Bowles Commission report in 2010, the fiscal outlook for the nation has improved. But the long-term debt problem has not been solved. The Center on Budget and Policy Priorities, based on figures from the Congressional Budget Office (CBO), projects that the ratio of the national debt to GDP will fall slightly from its current 74 percent to 73 percent by 2017. However, the ratio will then rise to 92 percent by 2040. This projection contrasts with the Center's 2010 projection in which the debt-to-GDP ratio increased by more than 200 percent.

Granted, this is good news. But not so fast. The assumptions built into the projections are likely to be too optimistic. The CRFB projects that under a more reasonable set of assumptions, the debt will rise to over 150 percent of GDP by 2040. As CRFB argues, the debt path under these more reasonable assumptions is, though improved, nonetheless "unsustainable."

Equally important, the big picture on the nation's budget shows that future spending increases in Social Security, Medicare and other health programs, and net interest will eat up all future increases in revenue. CBO projects that compared to average spending in these three budget categories between 1965 and 2014, spending as a percentage of GDP by 2040 on Social Security will increase by 55 percent, on federal health programs by 220 percent, and on interest on the debt by well over 100 percent. As a result, spending on everything else will decline by around 40 percent. No wonder a recent report from the Urban Institute shows that the share of federal spending on children has already begun to decline and will fall by nearly 30 percent between 2010 and 2024.

Despite the modest achievements of the latest budget deal, long-term budget prospects continue to look bleak and present spending priorities still emphasize programs for the elderly and interest on the debt while squeezing other programs, including those for children. Perhaps two cheers for the deal is one too many.

Editor's Note: this post first appeared in Real Clear Markets.

Editor's note: This post originally appeared in the New England Journal of Medicine's Perspective online series on April 22, 2015.

Congress has finally euthanized the sustainable growth rate formula (SGR). Enacted in 1997 and intended to hold down growth of Medicare spending on physician services, the formula initially worked more or less as intended. Then it began to call for progressively larger and more unrealistic fee cuts — nearly 30% in some years, 21% in 2015. Aware that such cuts would be devastating, Congress repeatedly postponed them, and most observers understood that such cuts would never be implemented. Still, many physicians fretted that the unthinkable might happen.

Now Congress has scrapped the SGR, replacing it with still-embryonic but promising incentives that could catalyze increased efficiency and greater cost control than the old, flawed formula could ever really have done, in a law that includes many other important provisions. How did such a radical change occur?  And why now?

The “how” was logrolling — the trading of votes by legislators in order to pass legislation of interest to each of them. Logrolling has become a dirty word, a much-reviled political practice. But the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA), negotiated by House leaders John Boehner (R-OH) and Nancy Pelosi (D-CA) and their staffs, is a reminder that old-time political horse trading has much to be said for it.

The answer to “why now?” can be found in the technicalities of budget scoring. Under the SGR, Medicare’s physician fees were tied through a complex formula to a target based on caseloads, practice costs, and the gross domestic product. When current spending on physician services exceeded the targets, the formula called for fee cuts to be applied prospectively. Fee cuts that were not implemented were carried forward and added to any future cuts the formula might generate. Because Congress repeatedly deferred cuts, a backlog developed. By 2012, this backlog combined with assumed rapid future growth in Medicare spending caused the Congressional Budget Office (CBO) to estimate the 10-year cost of repealing the SGR at a stunning $316 billion.

For many years, Congress looked the costs of repealing the SGR squarely in the eye — and blinked. The cost of a 1-year delay, as estimated by the CBO, was a tiny fraction of the cost of repeal. So Congress delayed — which is hardly surprising.

But then, something genuinely surprising did happen. The growth of overall health care spending slowed, causing the CBO to slash its estimates of the long-term cost of repealing the SGR. By 2015, the 10-year price of repeal had fallen to $136 billion. Even this number was a figment of budget accounting, since the chance that the fee cuts would ever have been imposed was minuscule. But the smaller number made possible the all-too-rare bipartisan collaboration that produced the legislation that President Barack Obama has just signed.

The core of the law is repeal of the SGR and abandonment of the 21% cut in Medicare physician fees it called for this year. In its place is a new method of paying physicians under Medicare. Some elements are specified in law; some are to be introduced later. The hard-wired elements include annual physician fee updates of 0.5% per year through 2019 and 0% from 2020 through 2025, along with a “merit-based incentive payment system” (MIPS) that will replace current incentive programs that terminate in 2018. The new program will assess performance in four categories: quality of care, resource use, meaningful use of electronic health records, and clinical practice improvement activities. Bonuses and penalties, ranging from +12% to –4% in 2020, and increasing to +27% to –9% for 2022 and later, will be triggered by performance scores in these four areas. The exact content of the MIPS will be specified in rules that the secretary of health and human services is to develop after consultation with physicians and other health care providers.

Higher fees will be available to professionals who work in “alternative payment organizations” that typically will move away from fee-for-service payment, cover multiple services, show that they can limit the growth of spending, and use performance-based methods of compensation. These and other provisions will ramp up pressure on physicians and other providers to move from traditional individual or small-group fee-for-service practices into risk-based multi-specialty settings that are subject to management and oversight more intense than that to which most practitioners are yet accustomed.

Both parties wanted to bury the SGR. But MACRA contains other provisions, unrelated to the SGR, that appeal to discrete segments of each party. Democrats had been seeking a 4-year extension of CHIP, which serves 8 million children and pregnant women. They were running into stiff head winds from conservatives who wanted to scale back the program. MACRA extends CHIP with no cuts but does so for only 2 years.  It also includes a number of other provisions sought by Democrats: a 2-year extension of the Maternal, Infant, and Early Childhood Home Visiting program, plus permanent extensions of the Qualified Individual program, which pays Part B Medicare premiums for people with incomes just over the federal poverty thresholds, and transitional medical assistance, which preserves Medicaid eligibility for up to 1 year after a beneficiary gets a job.

The law also facilitates access to health benefits. MACRA extends for two years states’ authority to enroll applicants for health benefits on the basis of data on income, household size, and other factors gathered when people enroll in other programs such as the Supplemental Nutrition Assistance Program, the National School Lunch Program, Temporary Assistance to Needy Families (“welfare”), or Head Start. It also provides $7.2 billion over the next two years to support community health centers, extending funding established in the Affordable Care Act.

Elements of each party, concerned about budget deficits, wanted provisions to pay for the increased spending. They got some of what they wanted, but not enough to prevent some conservative Republicans in both the Senate and the House from opposing final passage. Many conservatives have long sought to increase the proportion of Medicare Part B costs that are covered by premiums. Most Medicare beneficiaries pay Part B premiums covering 25% of the program’s actuarial value. Relatively high-income beneficiaries pay premiums that cover 35, 50, 65, or 80% of that value, depending on their income. Starting in 2018, MACRA will raise the 50% and 65% premiums to 65% and 80%, respectively, affecting about 2% of Medicare beneficiaries. No single person with an income (in 2015 dollars) below $133,501 or couple with income below $267,001 would be affected initially. MACRA freezes these thresholds through 2019, after which they are indexed for inflation. Under previous law, the thresholds were to have been greatly increased in 2019, reducing the number of high-income Medicare beneficiaries to whom these higher premiums would have applied. (For reference, half of all Medicare beneficiaries currently have incomes below $26,000 a year.)

A second provision bars Medigap plans from covering the Part B deductible, which is now $147. By exposing more people to deductibles, this provision will cause some reduction in Part B spending. Everyone who buys such plans will see reduced premiums; some will face increased out-of-pocket costs. The financial effects either way will be small.

Inflexible adherence to principle contributes to the political gridlock that has plunged rates of public approval of Congress to subfreezing lows. MACRA is a reminder of the virtues of compromise and quiet negotiation. A small group of congressional leaders and their staffs crafted a law that gives something to most members of both parties. Today’s appalling norm of poisonously polarized politics make this instance of political horse trading seem nothing short of miraculous.